Dystonic drop foot gait in a patient with manganism.

In 1983–1984, a 29-year-old battery factory worker gradually developed gait difficulties and tremor. In 1984, he was found to have severely elevated serum manganese levels and retired from work. Clinical examination in 1984 (videos 1–3 on the Neurology Web site at www.neurology.org) showed bilateral foot dystonia and profound parkinsonism. His gait was shuffling, although he lifted his knees relatively highly. Strength of foot dorsiflexors was normal. He did not respond to dopaminergic drugs and his gait disorder slowly deteriorated to an asymmetric dystonic drop foot gait (videos 4 and 5, recorded in 2008). Although the walking pattern of this patient with manganism resembled that of a strutting rooster, it was distinct from cock gait as classically described in manganism. Patients with classic cock gait walk on the metatarsophalangeal joints and their heels do not touch the ground.1,2